Vol 16 No 01 January-February 2019 83 MISCELLANEOUS Mean Platelet Volume and Testicular Torsion: New Findings Marta Peretti1, Nicola Zampieri1*, Mirko Bertozzi2 , Federica Bianchi1, Simone Patanè1, Valentina Spigo1, Francesco S. Camoglio1 Introduction: Testicular torsion is an emergency at any age; the aim of this study is to evaluate the role of mean platelet volume to assess the viability of the testes before surgery Materials and methods: We retrospectively analysed the medical records of consecutive patients who underwent surgical exploration for acute scrotal pathology between January 2014 and December 2016 in our institution. Patients were divided into two groups (detorsion of testes and orchyectomy); a third group was created as control group. All patients underwent blood exam before surgery; inclusion and exclusion criteria were created. We also evaluated the association between mean platelets volume and the testicular recovery during surgery Result: After reviewing medical charts following the inclusion and exclusion criteria, 8 patients were enrolled in Group 1 and 11 patients in Group 2. 33 healthy controls were enrolled in Group 3. MPV value in Group 1 resulted significantly different (p < 0.01) from the value in Group 2 and 3. The duration of symptoms was shorter than 6 hours in 4/8 (50%) patients in Group 1; this early referral to hospital allowed prompt detorsion and testicular recovery. In these “early-presenting” patients, MPV value was significantly lower than in patients with torsion of testicular appendage (p = 0.01) and in controls (p = 0.001). Conclusion: MPV could be a useful adjunct in diagnosing TT, aiding its differential diagnosis with Torsion of the testicular appendage. The lower MPV value in “early-presenting” patients with TT suggests a role in predicting the testis viability, and therefore the appropriate treatment. Keywords: mean platelet volume; pediatric; testicular torsion. INTRODUCTION Testicular torsion (TT) occurs in 1 out of 4000 males younger than 25 years(1). The differential diagnosis with other conditions, such as epididymo-orchitis (EO) and torsion of the testicular appendage (TTA), remains challenging. Testis’ viability decreases after 6 hours af- ter onset of symptoms, therefore a prompt diagnosis is necessary(2). The risk of testicular loss and unnecessary surgery improved the need for novel diagnostic tech- niques. Recent studies focused on the role of hemato- logic parameters, such as mean platelet volume (MPV), in diagnosing TT(3). The present study aimed to evaluate this parameter in diagnosing TT and in its differential diagnosis with other acute scrotal pathologies. MATERIALS AND METHODS We retrospectively analysed the medical records of consecutive patients who underwent surgical explora- tion for acute scrotal pathology between January 2014 and December 2016 in out institution, a tertiary refer- ral centre. Patients were divided into two groups: pa- tients diagnosed with TT (Group 1) and patients with other acute scrotal pathologies (Group 2). Patients with peri-natal (extravaginal) torsion and with history of scrotal trauma were excluded. Controls were selected among healthy subjects referring to our Hospital for 1Women and Child Hospital, Azienda Ospedaliera Universitaria Integrata, University Of Verona, Italy. 2Department of Pediatric Surgery, Azienda Ospedaliera di Perugia,University of Perugia. *Correspondence: Woman and Child Hospital, Azienda Ospedaliera Universitaria Integrata, Pediatric Surgical Unit, Piazzale Stefani 37134 Verona, Italy. E-mail: dr.zampieri@libero.it. Received July 2017 & Accepted November 2017 elective non-genitourinary surgery (Group 3); a com- plete blood count was performed as common practice before the surgical procedure. Patients from Group 1 and 2 had a blood count performed at time of the admis- sion at the emergency department (ED). Clinical fea- tures, colour Doppler ultrasound (CDUS) and labora- tory findings were compared. Duration of symptoms in Group 1 was classified as longer or shorter than 6 hours. Statistical analysis was performed using the Chi- Square, student t-test and Fisher exact tests with a P value less than .05 considered as significant. RESULTS During the study period 14 patients with testicular tor- sion, 19 with torsion of testicular appendage and 33 as controls were considered. After reviewing medical charts 8 patients were enrolled in Group 1 and 11 pa- tients in Group 2 and all 33 healthy controls in Group 3. those patients excluded were considered only for the mpv value but not for the timing of symptoms. Patients’ characteristics are resumed in Table 1. MPV value in Group 1 resulted significantly different (p < 0.01) from the value in Group 2 and 3 (Table 2). The duration of symptoms was shorter than 6 hours in 4/8 (50%) pa- tients in Group 1; this early referral to hospital allowed prompt detorsion and testicular recovery. In these “ear- ly-presenting” patients, MPV value was significantly lower than in patients with TTA (p = 0.01) and in con- trols (p = 0.001). All patients with TT underwent prompt scrotal explo- ration, with detorsion of the testis; viability was tested by testicluar puncture in three different zones. In cases of testicular necrosis, an orchiectomy was performed. No significant difference was evidenced in terms of MPV value between Group 2 and Group 3. No signifi- cant difference was found between Group 1 and Group 2 in terms of platelet (PLT) count. DISCUSSION Testicular torsion is an emergency condition which needs prompt recognition and treatment, in order to avoid gonadal necrosis and subsequent fertility impair- ment. The differential diagnosis with other acute scrotal pathologies, such as EO and TTA, can be challenging. Clinical and CDUS findings aid the diagnosis, but in certain cases they can lead to unnecessary scrotal explo- ration. As previously reported, clinical findings show high sensitivity but low specificity (4); on the other hand, CDUS shows specificity of 97-100%(5), but it is limited by high operator-dependence. In recent years, an effort has been made in order to find useful adjuncts in diagnosing TT. A study conducted by Günes and colleagues(6) found a significant difference in terms of neutrophil to lymphocyte ratio (NLR), plate- let to lymphocyte ratio (PLR) and PLT between patients with TT and controls, while no predictive role of MPV value was found. NLR and PLR couldn’t be evaluat- ed in our study, since these parameters aren’t routinary measured in our ED. A subsequent study conducted by Bitkin and colleagues(3) found PLT count and PLR to be useful in differentiating between epididymitis and TT. MPV value didn’t show significant difference between the EO and the TT groups. Moreover, recent studies(3,7) found MPV value significantly higher in the TT group than in the control group, in opposition to our findings. In the present study, 4 out of 8 (50%) patients with TT presented at the ED within 6 hours after onset of symp- toms, while 9 out of 10 (90%) patients with TTA re- ferred to hospital later. This finding is consistent with previous reports(7-9). Detorsion was possible in all these “early-presenting” patients, while orchiectomy was performed in the “late-presenting” ones; as reported in the literature, irreversible loss of the testicle begins after the first 6 hours(10). MPV value showed significant dif- ference between “early-presenting” patients (< 6 hours) in Group 1 and patients in Group 2 and 3 with a signif- icant cut-off of 6,5 fl. This finding suggests that MPV value could be an indicator of testis viability in selected patients. No significant difference was found between late-presenting patients in Group 1 and the other groups. In conclusion, MPV could be a useful adjunct in diag- nosing TT, aiding its differential diagnosis with TTA. The lower MPV value in “early-presenting” patients with TT suggests a role in predicting the testis viability, and therefore the appropriate treatment. Further large studies evaluating MPV role are needed. REFERENCES 1. Barada JH, Weingarten JL, Cromie WJ. Testicular salvage and age-related delay in the presentation of testicular torsion. J Urol. 1989;142(3):746-8. 2. Boettcher M, Bergholz R, Krebs TF, Wenke K, Aronson DC. Clinical predictors of testicular torsion in children. Urology. 2012;79(3):670- 4. 3. Bitkin A, Aydın M, Özgür BC, Irkilata L, Akgunes E, Keles M, Sarıcı H, Atilla MK. Can haematologic parameters be used for differential diagnosis of testicular torsion and epididymitis? Andrologia. 2017;00:e12819. 4. Lemini R, Guanà R, Tommasoni N, Mussa A, Di Rosa G, Schleef J. Predictivity of Clinical Findings and Doppler Ultrasound in Pediatric Acute Scrotum. Urol J. 2016;13(4):2779-83. 5. Tekgul S, Riedmiller H, Gerharz E, et al. Guidelines on Paediatric Urology. ESPU/ EAU 2011. 6. Güneş M, Umul M, Altok M, Akyuz M, İşoğlu CS, Uruc F, Aras B, Akbaş A, Baş E. Predictive role of hematologic parameters in testicular torsion. Korean J Urol. 2015; 56(4):324-9. 7. Cicek T, Togan T, Akbaba K, Narci H, Aygun C. The value of serum mean platelet volume in testicular torsion. J Int Med Res. 2015;43(3):452-9 8. Yang C, Song B, Liu X, Wei G, Tan J, He D. Acute scrotum in children. An 18-year retrospective study. Pediatr Emer Care 2011;27: 270-274. 9. Boettcher M1, Krebs T, Bergholz R, Wenke Table 1. General characteristics of study population Group 1 (n=8) Group 2 (n=11) Mean age (years) 13 (12-15) 10 (8-13) Side, left 4 (50) 7 (64) Symptoms duration < 6 hours 4 (50) 1 (10) Clinical findings Swelling 8 (100) 3 (27) Erythema 8 (100) 5 (45) Fever 1(12) 0 Vomit 2 (25) 0 CDUS, blood flow Absent 4 (57) 3 (43) Decreased - 1 (10) Equal - 5 (50) Increased - 4 (40) Detorsion 4 (50) - Table 2. Hematologic parameters of the study population Group 1 Group 2 Group 3 Mean age (years) 13 (12-15) 10 (8-13) 13 (10-17) Laboratory results MPV (fL) < 6 h 6.5 (5.5-7.4) 8.1 (6-10.1) 8.25 (7-10.2) > 6 h 6.18 (5.9-6.4) 6.83 (5.5-7.4) PLT (103/μL) 306.250 298.360 253.430 Mean values are shown (range) MPV, mean platelet volume PLT, platelet count Testicular Torsion and Mean Platelet Volume-Peretti et al. Miscellaneous 84 Vol 16 No 01 January-February 2019 85 Testicular Torsion and Mean Platelet Volume-Peretti et al. K, Aronson D, Reinshagen K. Clinical and sonographic features predict testicular torsion in children: a prospective study. BJU Int. 2013 Dec;112(8):1201-6. 10. Güneş M, Umul M, Altok M, et al. Is it possible to distinguish testicular torsion from other causes of acute scrotum in patients who underwent scrotal exploration? A multi- center clinical trial. Cent European J Urol. 2015;68(2):252-256. 11. Cimador M1, DiPace MR, Castagnetti M, DeGrazia E. Predictors of testicular viability in testicular torsion. J Pediatr Urol. 2007; 3(5):387-90.